Team concepts
Nurse peer evaluation: A roadmap to professional growth and development By Melissa L. Burchett, BSN, RN, CCM, and Mark Spivak, MSN, RN, BCEN
A
ccording to the American Nurses Association (ANA) Peer Review Guidelines, “peer review in nursing is the process by which practicing registered nurses systematically access, monitor, and make judgments about the quality of nursing care provided by peers as measured against professional standards of practice.”1 Peer review implies that nursing care should be evaluated by a clinical nurse of the same “rank or standing” according to established standards of practice.2 Since the ANA guidelines were introduced, the peer review process has become recognized as an essential component of current nursing practice from the ANA, Magnet Recognition Program®, and the Institute of Medicine.3 These governing bodies recognize nursing peer review as a self-regulatory practice model that incorporates clinical accountability and quality care while promoting professional growth and development. The ANA Peer Review Guidelines provide not only the structure for how nurses should evaluate the care that they provide, but also describe why and how the peer review process can elevate the nursing profession to the respected stature it deserves.1,2 Haag-Heitman and George reported that “nursing peer review is the missing essential element needed to assure that nurses hold each other accountable to improve these and other quality outcomes for patient care.”2 This is a powerful statement and indicates that it’s clinical nurses who must hold each other accountable for the care they deliver, instead of leaving that task entirely to managers, who seldom have as many opportunities to observe staff members in day-to-day operations. In consideration of these and other expert 18 August 2014 • Nursing Management
opinions, the profession of nursing can no longer disregard the valuable function that peer review has in providing quality care to patients, as well as improving patient outcomes. Although there’s evidence and information regarding the benefits of a formalized nursing peer review process, few healthcare organizations have implemented this process in a meaningful manner. Implementation of a formal peer review process will allow nursing to be recognized as a mature profession with a system in place to hold itself accountable for the delivery of safe, quality care. Nursing staff members on a progressive care unit decided to evaluate its need for a peer review process and then implement it into the culture. The starting point In order to facilitate a peer review process, an evaluative tool must be used to provide structure for the actual evaluation process. After a comprehensive search, the Nurse Advisory Board tool for peer evaluation was selected, modified, and evaluated for efficiency to meet the needs of the unit and the pilot program.4 This evaluation tool was chosen because it reviews both the quantitative and qualitative aspects of a peer’s perception of nursing practice. Participants in this pilot program responded using short, open-ended answers, as well as Likert scale responses. A thematic analysis of the short answers and frequencies of the Likert scale questions were then applied. Findings included identifying themes, strengths, weaknesses, and professional development interests of the staff participants. In order to minimize bias and ensure confidentiality, an individual from a different department compiled the data, and surveys were numbered only during the transcription process to prevent pairing responses with any participant. A convenience sample of progressive care nurses completed the original survey. Nurse participants were ages 23 to 50 (N = 18) and currently employed with the University of Louisville Hospital. Participation in the peer evaluation pilot was www.nursingmanagement.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Team concepts
www.nursingmanagement.com
5.60 5.42
5.41
5.36
5.40
5.28
5.26
Likert scale N = 18
5.20
5.07
5.00 4.77
4.80 4.64 4.60 4.40
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lis na sio
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4.20
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Continuing down the right path Meetings were initially held between the director, clinical manager, and advanced practice nurse educator to research, develop, and implement a formalized nursing peer review process based on the ANA Peer Review Guidelines, IOM recommendations, and the Magnet Recognition Program.1-3 Eight staff meetings were scheduled to review the peer evaluation tool, guidelines, and implementation for the nurse peer evaluation pilot. Upon completion of staff education, all participants on the progressive care unit were provided the self-evaluation tool to complete and return to the clinical manager. After staff identified interest in the pilot by returning the selfevaluation tool, three peer evaluators were randomly selected by drawing names from a group of eligible staff members. Criteria for eligibility included being a nurse for 1 year and an employee for 6 months on the unit, and no written counseling for behavior and/or attendance. During the feedback and evaluation phase, clinical nurses who participated in the peer review process were provided the evaluations completed by their peers in regard to their clinical practice. This feedback took place in a group meeting with the nurse being evaluated, the peer evaluators, educator, and clinical manager. Because this was a pilot project, the educator and clinical manager were in attendance only to facilitate and ensure that human resource standards and confidentiality
Figure 1: Nursing peer review process
Cl
voluntary and peer evaluators were randomized in a double-blind format. There were no negative consequences for nurses who chose not to participate in the survey. The Institutional Review Board approved this study with an exempt status.
Domains Clinical knowledge
Professionalism
Critical thinking
Management of responsibilities
Technical skills
Budget
Communication
Growth
were maintained. In addition to the role of facilitator, the educator and clinical manager were available to moderate and help reduce stress and anxiety of staff participants during the implementation of a new process. Strengths, weaknesses, and opportunities for practice were identified and discussed with the nurse being reviewed. Through this evaluation review, trends for unitspecific education and opportunities for professional growth and development were identified. (See Table 1 and Figure 1.) Opportunities for improvement were recorded in an effort to provide future-focused, unit-specific education. In addition to identifying opportunities for improvement, individual strengths, and professional growth, content experts on the unit were appointed as resources for
other staff members. Given that one of the goals of this pilot project was to improve interprofessional accountability, the discovery of content experts was an unanticipated, yet highly valuable, finding. For example, during one of the evaluations, a staff member was identified as having a firm understanding of the proper insertion and care of an indwelling urinary catheter. In order to take advantage of this nurse’s knowledge, she was identified to the rest of the unit as the subject matter expert on this topic to achieve the hospital initiative of reducing catheterassociated urinary tract infections. Finding the destination The benefits of peer review are to evaluate nursing care, communication, clinical competencies, teamwork, and constructive feedback to promote
Nursing Management • August 2014 19
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Team concepts Table 1: Thematic analysis of qualitative data Positive findings
Negative findings
Clinical knowledge
Good clinical skills and able to perform all duties independently
Knowledge of pathophysiology and pharmacology
Critical thinking
Ability to recognize change in patient status and need for intervention
Recognition of when to ask for assistance
Technical skills
Knowledgeable and demonstrates Technology and equipment used competency in taking care of in the medical field; technology complex patients constantly changing
Communication
Rapport with patients and families, constant patient advocate
Fear of addressing conflicts, solving disputes, and hurting people's feelings
Professionalism
Ability to work as a team, always prepared, and willing to help when needed
Difficult to take constructive criticism as a building tool
Management of responsibilities
Ability to track multiple responsibilities for self and others
Delegation to peers and ancillary staff members
professional growth, development, and accountability. Additional benefits include increased job satisfaction and nurse retention, a positive work and peer-related environment, accountability, and quality improvement.5 According to staff feedback on the evaluation tool, additional benefits included knowledge of commitment to patient advocacy, ability to work together as a team, demonstrated competency in caring for complex patients, and the ability to recognize changes in patient conditions and the need for intervention. The benefits didn’t come without challenges or perceived barriers to implementation, which included: • lack of staff involvement • anxiety • timely feedback • amount of time needed to complete the survey • effectiveness of the tools • communication used in the process • support from nursing leadership
• knowledge deficit of peer evaluation • ability to change a cultural setting within a profession. These challenges are significant and must be addressed in the initial phases of the implementation process through education, open dialog, and leadership support. The peer review process can be used to recognize learning needs, develop educational tools specific to the identified learning needs, and gain skills for professional practice.5 Education, training, structure, and a formalized process for completing and communicating the peer review process should be identified by the staff, manager, and educator to provide reliability and validity. Before the start of the peer review process, a determination should be made as to whether the peer feedback will be presented in a written or verbal format, who will have access to the peer review, and if the review should be incorporated into the yearly evaluation process.
20 August 2014 • Nursing Management
Empowerment starts here The ultimate goal of the peer evaluation process is to empower staff members to hold each other accountable for the care that they provide, which should then increase competency, autonomy, and professional growth and development. Although it’s too early to measure the direct benefits to patient outcomes, future studies should focus on quality indicators and professional growth and development of staff. Future research on peer evaluation should include, but not be limited to, examining best practices; quality improvement; and nurse retention, satisfaction, and engagement. The concept of peer review continues to be a critically undeveloped measure of nursing that ensures quality care, autonomy, competency, and professional development. NM
REFERENCES 1. American Nurses Association. Peer Review Guidelines. Kansas City, MO: American Nurses Association; 1988. 2. Haag-Heitman B, George V. Peer Review in Nursing: Principles for Successful Practice. Sudbury, MA: Jones and Bartlett Publishers; 2011. 3. Institute of Medicine. The future of nursing: leading change, advancing health. http://www.iom.edu/Reports/2010/ The-future-of-nursing-leading-changeadvancing-health.aspx. 4. The Advisory Board. Building peer accountability: toolkit for improving communication and collaboration. http://www. advisory.com/research/nursing-executivecenter/studies/2011/building-peeraccountability. 5. Davis KK, Capozzoli J, Parks J. Implementing peer review: guidelines for managers and staff. Nurs Adm Q. 2009;33(3):251-257. At the University of Louisville (Ky.) Hospital, Melissa L. Burchett is a clinical nurse manager and Mark Spivak is an advanced practice nurse educator. The authors have disclosed that they have no financial relationships related to this article. DOI-10.1097/01.NUMA.0000452005.79838.bc
www.nursingmanagement.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Nurse peer evaluation: A roadmap to professional growth and development By Melissa L. Burchett, BSN, RN, CCM, and Mark Spivak, MSN, RN, BCEN
A
ccording to the American Nurses Association (ANA) Peer Review Guidelines, “peer review in nursing is the process by which practicing registered nurses systematically access, monitor, and make judgments about the quality of nursing care provided by peers as measured against professional standards of practice.”1 Peer review implies that nursing care should be evaluated by a clinical nurse of the same “rank or standing” according to established standards of practice.2 Since the ANA guidelines were introduced, the peer review process has become recognized as an essential component of current nursing practice from the ANA, Magnet Recognition Program®, and the Institute of Medicine.3 These governing bodies recognize nursing peer review as a self-regulatory practice model that incorporates clinical accountability and quality care while promoting professional growth and development. The ANA Peer Review Guidelines provide not only the structure for how nurses should evaluate the care that they provide, but also describe why and how the peer review process can elevate the nursing profession to the respected stature it deserves.1,2 Haag-Heitman and George reported that “nursing peer review is the missing essential element needed to assure that nurses hold each other accountable to improve these and other quality outcomes for patient care.”2 This is a powerful statement and indicates that it’s clinical nurses who must hold each other accountable for the care they deliver, instead of leaving that task entirely to managers, who seldom have as many opportunities to observe staff members in day-to-day operations. In consideration of these and other expert 18 August 2014 • Nursing Management
opinions, the profession of nursing can no longer disregard the valuable function that peer review has in providing quality care to patients, as well as improving patient outcomes. Although there’s evidence and information regarding the benefits of a formalized nursing peer review process, few healthcare organizations have implemented this process in a meaningful manner. Implementation of a formal peer review process will allow nursing to be recognized as a mature profession with a system in place to hold itself accountable for the delivery of safe, quality care. Nursing staff members on a progressive care unit decided to evaluate its need for a peer review process and then implement it into the culture. The starting point In order to facilitate a peer review process, an evaluative tool must be used to provide structure for the actual evaluation process. After a comprehensive search, the Nurse Advisory Board tool for peer evaluation was selected, modified, and evaluated for efficiency to meet the needs of the unit and the pilot program.4 This evaluation tool was chosen because it reviews both the quantitative and qualitative aspects of a peer’s perception of nursing practice. Participants in this pilot program responded using short, open-ended answers, as well as Likert scale responses. A thematic analysis of the short answers and frequencies of the Likert scale questions were then applied. Findings included identifying themes, strengths, weaknesses, and professional development interests of the staff participants. In order to minimize bias and ensure confidentiality, an individual from a different department compiled the data, and surveys were numbered only during the transcription process to prevent pairing responses with any participant. A convenience sample of progressive care nurses completed the original survey. Nurse participants were ages 23 to 50 (N = 18) and currently employed with the University of Louisville Hospital. Participation in the peer evaluation pilot was www.nursingmanagement.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Team concepts
www.nursingmanagement.com
5.60 5.42
5.41
5.36
5.40
5.28
5.26
Likert scale N = 18
5.20
5.07
5.00 4.77
4.80 4.64 4.60 4.40
th Gr ow
et dg Bu
ag re
M
sp
of
an
es
m m Co
on em sib en ilit t of ie s
lis na sio
ic un
ca ni ch Te
m
n at io
kil ls
nk hi lt ca iti
Cr
Pr
g in
e dg le ow kn al ic
ls
4.20
in
Continuing down the right path Meetings were initially held between the director, clinical manager, and advanced practice nurse educator to research, develop, and implement a formalized nursing peer review process based on the ANA Peer Review Guidelines, IOM recommendations, and the Magnet Recognition Program.1-3 Eight staff meetings were scheduled to review the peer evaluation tool, guidelines, and implementation for the nurse peer evaluation pilot. Upon completion of staff education, all participants on the progressive care unit were provided the self-evaluation tool to complete and return to the clinical manager. After staff identified interest in the pilot by returning the selfevaluation tool, three peer evaluators were randomly selected by drawing names from a group of eligible staff members. Criteria for eligibility included being a nurse for 1 year and an employee for 6 months on the unit, and no written counseling for behavior and/or attendance. During the feedback and evaluation phase, clinical nurses who participated in the peer review process were provided the evaluations completed by their peers in regard to their clinical practice. This feedback took place in a group meeting with the nurse being evaluated, the peer evaluators, educator, and clinical manager. Because this was a pilot project, the educator and clinical manager were in attendance only to facilitate and ensure that human resource standards and confidentiality
Figure 1: Nursing peer review process
Cl
voluntary and peer evaluators were randomized in a double-blind format. There were no negative consequences for nurses who chose not to participate in the survey. The Institutional Review Board approved this study with an exempt status.
Domains Clinical knowledge
Professionalism
Critical thinking
Management of responsibilities
Technical skills
Budget
Communication
Growth
were maintained. In addition to the role of facilitator, the educator and clinical manager were available to moderate and help reduce stress and anxiety of staff participants during the implementation of a new process. Strengths, weaknesses, and opportunities for practice were identified and discussed with the nurse being reviewed. Through this evaluation review, trends for unitspecific education and opportunities for professional growth and development were identified. (See Table 1 and Figure 1.) Opportunities for improvement were recorded in an effort to provide future-focused, unit-specific education. In addition to identifying opportunities for improvement, individual strengths, and professional growth, content experts on the unit were appointed as resources for
other staff members. Given that one of the goals of this pilot project was to improve interprofessional accountability, the discovery of content experts was an unanticipated, yet highly valuable, finding. For example, during one of the evaluations, a staff member was identified as having a firm understanding of the proper insertion and care of an indwelling urinary catheter. In order to take advantage of this nurse’s knowledge, she was identified to the rest of the unit as the subject matter expert on this topic to achieve the hospital initiative of reducing catheterassociated urinary tract infections. Finding the destination The benefits of peer review are to evaluate nursing care, communication, clinical competencies, teamwork, and constructive feedback to promote
Nursing Management • August 2014 19
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Team concepts Table 1: Thematic analysis of qualitative data Positive findings
Negative findings
Clinical knowledge
Good clinical skills and able to perform all duties independently
Knowledge of pathophysiology and pharmacology
Critical thinking
Ability to recognize change in patient status and need for intervention
Recognition of when to ask for assistance
Technical skills
Knowledgeable and demonstrates Technology and equipment used competency in taking care of in the medical field; technology complex patients constantly changing
Communication
Rapport with patients and families, constant patient advocate
Fear of addressing conflicts, solving disputes, and hurting people's feelings
Professionalism
Ability to work as a team, always prepared, and willing to help when needed
Difficult to take constructive criticism as a building tool
Management of responsibilities
Ability to track multiple responsibilities for self and others
Delegation to peers and ancillary staff members
professional growth, development, and accountability. Additional benefits include increased job satisfaction and nurse retention, a positive work and peer-related environment, accountability, and quality improvement.5 According to staff feedback on the evaluation tool, additional benefits included knowledge of commitment to patient advocacy, ability to work together as a team, demonstrated competency in caring for complex patients, and the ability to recognize changes in patient conditions and the need for intervention. The benefits didn’t come without challenges or perceived barriers to implementation, which included: • lack of staff involvement • anxiety • timely feedback • amount of time needed to complete the survey • effectiveness of the tools • communication used in the process • support from nursing leadership
• knowledge deficit of peer evaluation • ability to change a cultural setting within a profession. These challenges are significant and must be addressed in the initial phases of the implementation process through education, open dialog, and leadership support. The peer review process can be used to recognize learning needs, develop educational tools specific to the identified learning needs, and gain skills for professional practice.5 Education, training, structure, and a formalized process for completing and communicating the peer review process should be identified by the staff, manager, and educator to provide reliability and validity. Before the start of the peer review process, a determination should be made as to whether the peer feedback will be presented in a written or verbal format, who will have access to the peer review, and if the review should be incorporated into the yearly evaluation process.
20 August 2014 • Nursing Management
Empowerment starts here The ultimate goal of the peer evaluation process is to empower staff members to hold each other accountable for the care that they provide, which should then increase competency, autonomy, and professional growth and development. Although it’s too early to measure the direct benefits to patient outcomes, future studies should focus on quality indicators and professional growth and development of staff. Future research on peer evaluation should include, but not be limited to, examining best practices; quality improvement; and nurse retention, satisfaction, and engagement. The concept of peer review continues to be a critically undeveloped measure of nursing that ensures quality care, autonomy, competency, and professional development. NM
REFERENCES 1. American Nurses Association. Peer Review Guidelines. Kansas City, MO: American Nurses Association; 1988. 2. Haag-Heitman B, George V. Peer Review in Nursing: Principles for Successful Practice. Sudbury, MA: Jones and Bartlett Publishers; 2011. 3. Institute of Medicine. The future of nursing: leading change, advancing health. http://www.iom.edu/Reports/2010/ The-future-of-nursing-leading-changeadvancing-health.aspx. 4. The Advisory Board. Building peer accountability: toolkit for improving communication and collaboration. http://www. advisory.com/research/nursing-executivecenter/studies/2011/building-peeraccountability. 5. Davis KK, Capozzoli J, Parks J. Implementing peer review: guidelines for managers and staff. Nurs Adm Q. 2009;33(3):251-257. At the University of Louisville (Ky.) Hospital, Melissa L. Burchett is a clinical nurse manager and Mark Spivak is an advanced practice nurse educator. The authors have disclosed that they have no financial relationships related to this article. DOI-10.1097/01.NUMA.0000452005.79838.bc
www.nursingmanagement.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
